Provider Demographics
NPI:1104914639
Name:COUNTRY WINDS MANOR, INC.
Entity type:Organization
Organization Name:COUNTRY WINDS MANOR, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:OGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-547-2398
Mailing Address - Street 1:21668 80TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-8412
Mailing Address - Country:US
Mailing Address - Phone:563-547-2398
Mailing Address - Fax:563-547-4274
Practice Address - Street 1:21668 80TH ST
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-8412
Practice Address - Country:US
Practice Address - Phone:563-547-2398
Practice Address - Fax:563-547-4274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IACCDI-478311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0809079Medicaid
IA165527Medicare Oscar/Certification